Financial disclosures: The authors have no conflicts of interest relevant to the content of this article. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of Defense, US Army or the Government

Key words: insomnia, ADHD, obesity, breathing problems, pediatrics.

Abstract: Attention deficit hyperactivity disorder is a commonly diagnosed condition in the pediatric as well as adult psychiatric population. Attention deficit hyperactivity disorder has undoubtedly been over diagnosed and treated with both stimulants and non-stimulants over the past few decades. Behavior problems in children are commonly noticed both by parents and teachers, leading to the formulation of attention deficit hyperactivity disorder diagnosis. Insomnia, on the other hand, is not as readily detected by parents and may result in behavioral problems at school. Several medical conditions responsible for causing insomnia may need to be ruled out before the diagnosis of attention deficit hyperactivity disorder is confirmed. In this article, we highlight symptoms common both to insomnia and attention deficit hyperactivity disorder by development of a checklist to help delineate the two conditions. The purpose of this checklist is to provide informational and educational tools both for parents and teachers to distinguish insomnia from attention deficit hyperactivity disorder. The ultimate goal of this paper is to improve diagnostic screening for attention deficit hyperactivity disorder by excluding conditions such as insomnia that may masquerade as attention deficit hyperactivity disorder.

Background

The association of attention deficit hyperactivity disorder (ADHD) with insomnia is well cited in literature;[1–3] however, the significance of this association is not well documented in the exclusionary diagnostic criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM) for either condition.[4] Clinically, the most common condition mimicking ADHD symptoms results from complications related to insomnia/sleep disturbances, whether primary or secondary in origin.[5] Inability to recognize insomnia may lead to confusion of clinical symptoms of irritability, hyperactivity, forgetfulness, and lack of attention, focus and concentration, with ADHD.[6] While most adults have the ability to verbalize symptoms of insomnia, children are unlikely to complain, but rather act out, presenting with behavioral problems resulting from fatigue and sleep deprivation.[7] Therefore, insomnia in children is a clinically important diagnostic consideration before confirming the diagnosis of ADHD, as insomnia can be reversible.

Symptoms of insomnia often mimic symptoms of ADHD in children; however, the two conditions can be differentiated by educating parents with the help of a proposed screening tool. Below is the list of secondary conditions causing insomnia that may result in ADHD like symptoms.

OSA. OSA is now common among children with obesity, and correlation of ADHD in children with obesity and OSA is gaining recognition.[10] Symptoms of OSA, such as snoring, choking, and fatigue, are noticeable, but frequently ignored by parents. Insomnia-related complications experienced by children during the day/at school, such as fatigue, lack of attention, focus, and concentration, are perceived and frequently reported as symptoms of ADHD by teachers.[11]

Nasal septal defects and nasal fractures. Nasal septal defects and nasal fractures are examples of anatomical defects of the septum that can cause chronic trouble breathing, which in turn may lead to insomnia and thus may present as symptoms of ADHD in primary care settings.[12] However, a careful examination of patient history could help clarify and rule out the diagnosis.

Adenoid hyperplasia and enlarged tonsils. Adenoid hyperplasia and enlarged tonsils are very common among children and are known to obstruct the airway causing congestion and difficulty breathing, potentially keeping children awake at night.[13,14]

Bronchial asthma and bronchitis. Bronchial asthma and bronchitis are major causes of insomnia in children, especially in combination with allergies and treatments associated with sleep/wake cycle disturbances.

Pain. Pain, either acute or chronic due to infections, illnesses, or injuries, is another potential contributor to increased discomfort and irritability leading to sleep disturbances.[15,16]

Psychiatric disorders. Psychiatric disorders, such as nocturnal enuresis/encopresis, parasomnias, tics, seizures, anxiety, depression, eating disorders, bipolar disorders, and schizophrenia, are serious concerns that, in pediatrics, could lead to secondary causes of insomnia. Psychiatric illness needs to be ruled out in children with insomnia, as ADHD is a comorbidity associated frequently with other psychiatric conditions.[17–20]

Poor diet. Poor diet includes unhealthy eating such as high sugar and caffeine-containing drinks near bedtime, resulting in stimulation and hyperactivity, thus decreasing restful sleep.[21] Poor sleep hygiene (e.g., use of computers before bed, sleeping with lights or electronics on, inconsistent sleep hours) may also result in symptoms resembling ADHD.

Substance abuse/exposure to toxic substances. Substance abuse[22] and exposure to toxic substances[23] in children have significant impact on a child’s behavior and are well described in literature. Alcohol abuse is frequently comorbid with ADHD and is a major concern in adolescents.[24] Insomnia due to substance abuse may further increase ADHD-like symptoms.

Exposure to cigarette smoke, environmental pollutants, and alcohol (i.e., fetal alcohol syndrome)[25] are other potential causes for concern for insomnia.

Medications. Medications, both prescription and over the counter, can play a major role in sleep regulation in children as well as adults.[26] Monitoring of dosings, timings, and concerns for abuse are critical in sorting associated behavioral changes.

Checklist

The aim of the proposed checklist is to improve the ability to diagnose and differentiate patients suffering from insomnia presenting as ADHD. Determination of underlying condition by ruling out potential differential diagnoses raises the accuracy of the target diagnosis, in this case ADHD. Exclusionary criteria, therefore, can play essential role in identification of both conditions. The checklist (Appendix 1) consists of nine simple questions with ‘yes or no’ responses to identify the conditions that commonly present with similar symptoms.

Conclusion

We hypothesize that, dimensional outlook as opposed to current categorical approach, may have more relevance in the accurate diagnosis of psychiatric disorders such as ADHD and insomnia. Meanwhile, we hope that introduction of the proposed checklist to the general public and clinicians alike may contribute to reduction in the rapid increase of diagnosis and unwarranted treatment of ADHD both in children as well as adults.